In recent years, healthcare service providers have been making the transition from manual paper-based medical records to an electronic format. Commercially available computer software, such as PowerChart®, PowerChart Office®, and other Cerner Millennium® applications marketed by Cerner Corporation of Kansas City, Mo. have advanced the state of the art well beyond the conventional manual approach. Electronic-based records substantially increase the efficiency of healthcare providers and institutions. Electronic medical records also substantially reduce risks associated with high volumes of patient data and potential liabilities arising out of clerical errors or misinformation. The electronic format enhances communication between various providers and within institutions. As electronic clinical documentation continues to become increasingly prevalent, the variety of applications, electronic forms, electronic charts, and user interfaces, as well as the corresponding versatility of this format, continue to expand.
Dictation is commonly used by physicians and other healthcare providers to memorialize relevant information associated with patient interactions. For example, a physician may recite a summary of symptoms presented by a particular patient as well as the physician's probable diagnosis, intended plan of treatment, and any necessary follow-up steps. Dictation is often performed using tape recorders or other mechanical audio recording devices, and must be labeled and sent to a transcriptionist. Dictation cassettes can be mislabeled or lost, and are not an efficient means of preserving audio data that is to accompany medical records. Digital dictation devices are becoming more common, but even with this new medium, digital dictation files still must be imported, attached, or otherwise appended to existing records. Similar problems can arise with misidentification and mishandling of these unassociated electronic audio files within vast medical information systems.
In addition, many currently available forms of electronic clinical documentation are limited in their ability to combine multiple modes of data entry. For example, conventional electronic clinical forms do not allow a user to simultaneously import system-generated text, embed audio data, receive free-text, and receive structured input; nor do conventional forms allow a user to enter these multiple modes of data at multiple locations within an electronic clinical document. Some types of electronic medical documentation available today allow a user to merely attach an audio file to the documentation. This form of documentation is inadequate, however, as attachments to electronic medical records suffer from various problems. For example, transcriptionists tasked with transcribing the audio file generally do not have the benefit of seeing and understanding the context of the audio file within the electronic clinical document. As a result, the accuracy of the resulting transcription is mediocre, at best. Further, a physician or other provider who has recorded audio relevant to the documentation typically does not have access to the audio file once it is sent to be transcribed. As such, if the physician desires to review, edit or add to the dictated information, the physician must wait until the transcribed audio file is returned, which is inefficient and frustrating.